Johns Hopkins Hospital System

Commuter Request Form

MTA passes are deducted as a pre-taxed benefit. The payments are paid through the first paycheck for the next month’s pass. MTA monthly passes are distributed by the Human Resources Office — Nelson 7.

Name(Required)

First Last

Personnel #(Required)

Work Ext(Required)

Request type:(Required)

Enrollment

Change

Termination

Organization:(Required)

Johns Hopkins Health System Corporation

The Johns Hopkins Hospital

Johns Hopkins Community Physicians

Select your pass for the bus, metro subway and light rail:(Required)

Regular – $74

Express – $93

Senior (65+) or Disability – $22

A picture ID is required when using a senior or disability pass.

Please check the box to authorize paycheck deductions. Note: It will take 30 days to start the deduction for the MTA pass.(Required)

I authorize JHHSC/JHH to deduct the above amount from my paycheck. This authorization will remain in effect until I have canceled it in writing, at least 30 days prior to the effective to enroll and/or the cancellation date. I understand that passes are non-transferable. I will pick up my pass at the below location prior to the 9th day of the following month.

Please check the box to authorize termination.(Required)

I authorize JHHS to stop deducting the above amount from my paycheck. This authorization will remain in effect until I submit a request for deductions to resume.

Signature (enter your full name):(Required)

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